Mt Bachelor Memory Care

Based on observation, interview, and record review, it was determined the facility failed to conduct ongoing quality improvement programs that evaluated services, resident outcomes and resident satisfaction. Findings include, but are not limited to:

During the survey, conducted 10/06/25 through 10/10/25, a quality improvement program developed to ensure adequate resident care, services and satisfaction was found to be ineffective.

Refer to the deficiencies in the report.

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause were reported to the local Seniors and People with Disability (SPD) office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the injury was not the result of abuse for 3 of 4 sampled residents (#s 1, 2 and 4) whose incidents were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the community in 05/2023 with diagnoses including dementia.

On 09/01/25, staff created an ISP (interim service plan) identifying a “cut (scabbed/ inflammed [sic])” on the resident’s left index finger.

On 09/26/25, staff created an ISP identifying a “ping pong size yellow bruise on right shoulder blade.”

There was no documented evidence that either injury of unknown cause was immediately investigated to rule out abuse.

During an interview at 1:20 pm on 10/08/25, Staff 1 (Administrator) confirmed the above injuries lacked investigation and had not been reported to the local SPD office. The surveyor requested the above injuries be reported to the local SPD office, and confirmation was received at 3:44 pm on 10/08/25.

The need to ensure injuries of unknown cause were reported to the local SPD office as suspected abuse unless an immediate facility investigation reasonably ruled out abuse was reviewed with Staff 1, Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:00 am. They acknowledged the findings.


2. Resident 4 moved into the community in 10/2024 with diagnoses including dementia.

The resident’s clinical record was reviewed, and the following was revealed:

* 08/07/25 – Injury of unknown cause, staff identified a bruise to the resident’s right shoulder;
* 08/14/25 – The resident experienced a fall and sustained a skin tear and bruising to the left knee;
* 09/19/25– Injury of unknown cause, staff identified a scab on the resident’s right upper thigh.

On 10/08/25 at 1:48 pm, Staff 1 (Administrator) acknowledged there was no investigation to rule out abuse or neglect for the above incidents.

The facility failed to promptly investigate the resident's fall with injury and injuries of unknown cause to rule out abuse or report the injuries to SPD as suspected abuse. The facility was instructed to report the fall with injury and injuries of unknown cause to the local SPD office. Proof of reporting was received by the survey team prior to survey exit.

The need to ensure all injuries including injuries of unknown cause were reported to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse, was discussed with Staff 1, Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 10:25 am. They acknowledged the findings.


3. Resident 2 moved into the community in 09/2023 with diagnoses including dementia.

The resident’s clinical record was reviewed, and the following was revealed:

On 09/28/25 the resident had an injury fall while “ambulating without [his/her] walker and wheelchair not within reach”. The description of the event also noted s/he “had one shoe on.” The resident returned from the hospital with a wrist fracture.

On 10/07/25 at 12:40 pm, Staff 1 confirmed she completed the follow-up action while investigating the fall with injury but had not ruled out abuse.

The facility failed to promptly investigate the resident's fall with injury to rule out abuse or report the injury to SPD as suspected abuse.

Survey requested the facility report the injury fall to the local SPD office, and confirmation was received at 10/08/25 at 3:40 pm.

The need to ensure all incidents contained all required areas of documentation including if abuse could be ruled out, and if not, incidents were reported to the local SPD office, was discussed with Staff 1, Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all required elements were addressed in the initial evaluation for 1 of 1 sampled resident (#3) whose initial evaluation was reviewed. Findings include but are not limited to:

Resident 3 was admitted to the facility on 09/04/25 with diagnoses including dementia and depression.

The resident’s initial evaluation, dated 08/30/25, was reviewed. The evaluation failed to address the following required elements:

* Preferred name, pronouns, and gender identity;
* Customary routines: eating, bathing;
* Interests, hobbies, social, leisure activities;
* Mental health issues including history of treatment and effective non-drug interventions;
* List of treatments: type, frequency, and level of assistance; and
* Emergency evacuation ability.
* Personality including how the person copes with change or challenging situations;
* Nutrition habits;
* List of treatments: type, frequency, and level of assistance; and
* Emergency evacuation ability.

The need to address all required areas in each initial evaluation was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 10/09/25 at 11:31 am. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents’ service plans were readily available to staff, were reflective of residents’ current care needs and preferences, provided clear direction to staff regarding the delivery of services, and/or service plans were implemented for 3 of 4 sampled residents (#s 1, 2, and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the community in 05/2023 with diagnoses including dementia.

The resident’s clinical record was reviewed, observations were made, and interviews were conducted. The following was identified:

a. During the entrance interview on 10/06/25, facility staff reported service plans were stored in the service plan binder located outside the MT office in each unit for direct care staff to review. Upon observation of the binder stored on a cart outside the MT office in the Riverside unit at 2:48 pm on 10/06/25, the service plan for Resident 1 was dated 05/20/25. A service plan dated 09/26/25 was provided by the facility at 1:30 pm on 10/07/25, but this was not available to staff at the time of survey entrance.

b. The 09/26/25 service plan was not reflective of the resident’s current care needs and did not give clear direction to the staff in the following areas:

* History of unexplained weight loss; and
* Emergency evacuation assistance.

The need to ensure residents’ current service plans were readily available to staff, were reflective of the resident’s status and care needs, and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1(Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:00 am. They acknowledged the findings.


2. Resident 4 moved into the community in 10/2024 with diagnoses including dementia.

Observations were made, and interviews with staff were conducted. On 10/06/25 at 11: 47 am, the resident's current service plan, dated 09/12/25, was not available to staff. The service plan was not reflective of the resident's needs and preferences, did not provide clear instructions to staff or was not implemented in the following areas:


* Behaviors, including interventions;
* Toileting;
* Pain, including how the resident expresses pain;
* Fall interventions; and
* Emergency evacuation assistance.

The need to ensure service plans were available, provided clear direction to staff, were reflective of resident needs and preferences, and were implemented was discussed with Staff 1, (Administrator) Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 10: 25 am. They acknowledged the findings.


3. Resident 2 moved into the community in 09/2023 with diagnoses including dementia.

The resident’s clinical record was reviewed, observations were made, and interviews were conducted. The following was identified:

a. During the entrance interview on 10/06/25, facility staff reported service plans were stored in the service plan binder located outside the MT office in each unit for direct care staff to review. Upon observation of the binder stored on a dining room table outside the MT office in the Mountainside unit at 2:50 pm on 10/06/25, the service plan for Resident 2 was dated 06/23/25. A service plan dated 09/19/25 was provided by the facility at 3:15 pm on 10/06/25, but this was not available to staff at the time of survey entrance.

b. The 09/19/25 service plan was not reflective of the resident’s current care needs, and/or lacked clear instructions in the following areas:

* Emergency evacuation assistance;
* Outside provider services, including HH PT and OT;
* How the resident exhibits anxiety and agitation;
* Non-pharmaceutical interventions for behaviors;
* Preferences for sleeping and bathing; and
* Ability to communicate and understand others.


During an interview on 10/09/25 at 1:15 pm, Staff 4 (CG) acknowledged communication with Resident 2 was “hard to figure out” because s/he was emotional, “cries more” and then takes time to figure out what s/he is trying to communicate.

The need to ensure residents’ current service plans were readily available to staff, were reflective of the resident’s status and care needs, and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1(Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed, interventions were communicated to staff, the condition was monitored at least weekly to resolution and interventions were re-evaluated to determine effectiveness and/or failed to evaluate residents who experienced a significant change in condition, refer to the facility nurse, document the change, and update the service plan for 4 of 4 sampled residents (#s 1, 2, 3 and 4) who experienced changes of condition. Resident 2 experienced severe ongoing weight loss and ongoing falls with injuries including a wrist fracture and Resident 4 experienced severe ongoing weight loss. Findings include, but are not limited to:

1. Resident 4 moved into the community in 10/2024 with diagnoses including dementia.

Resident 4’s weight record noted the following:

* 05/05/25 – 117.2 pounds;
* 06/04/25 – 106.9 pounds;
* 07/14/25 – 96.4 pounds;
* 08/02/25 – 101.2 pounds;
* 09/07/25 – 97.9 pounds;
* 10/05/25 – 90 pounds; and
* 10/07/25 – 96 pounds.


Between 05/05/25 and 06/04/25, the resident was noted to have lost 10.3 pounds, or 8.78% of his/her total body mass in one month. This constituted a severe weight loss and required an RN assessment.

There was no documented evidence the facility evaluated Resident 4, referred to the facility nurse, documented the change, and updated the resident’s service plan when the severe weight loss was discovered. The resident continued to lose weight.



* 08/08/25 - The facility communicated with the resident’s PCP, noting the resident’s weight loss and resulting in an order to increase administration of protein shakes from twice daily to three times daily at 8:00 am, 1:00 pm and 6:00 pm; and

* 08/14/25 - Progress note “…Resident has had a significant [weight] loss of 17 pounds in the last six months, PCP has been notified and orders received, encourage protein shakes and monitor caloric intake as well as weigh weekly.

In an interview with Staff 1 (Administrator) on 10/08/25 at 11:02 am, she confirmed the facility did not evaluate Resident 4 for the severe weight loss, refer the resident to the facility nurse, document the change and update the resident’s service plan when the severe weight loss was initially discovered. She confirmed the facility had not monitored the interventions for Resident 4’s severe ongoing weight loss for effectiveness or determined if new interventions were needed and the resident continued to lose weight through 10/05/25.


The facility's failure to evaluate Resident 4 for severe weight loss when first detected, put the resident’s health and safety at risk for further weight loss.


b. Review of Resident 4’s progress notes dated 07/06/25 through 10/06/25, it was noted the following short- term changes of condition:


* 08/07/25 - Injury of unknown cause, bruise to the right shoulder;
* 08/14/25 - The resident experienced a fall with a skin tear and bruising to the right knee; and
* 09/19/25 - Injury of unknown cause, scab on right upper thigh.


There was no documented evidence these reportable events were monitored with progress noted at least weekly to resolution.

The need to evaluate residents who experienced significant changes in condition, refer to the facility nurse, document as required, monitor interventions for effectiveness and monitor short-term changes of condition with progress noted at least weekly to resolution was reviewed with Staff 1, Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 10:25 am. They acknowledged the findings.



2. Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia.


The resident's 09/19/25 service plan, 07/07/25 through 10/06/25 progress notes, weight records, and interim service plans (ISP) were reviewed.


a. The service plan indicated Resident 2 required a gluten free diet and needed “reminding/cueing to maintain adequate intake." Resident 2 was on thin liquids and a regular texture diet.


Resident 2’s weight records were reviewed during the survey and revealed the following:



* 08/07/25: 119.8 pounds;
* 09/05/25: 111.8 pounds; and
* 10/09/25: 107 pounds (requested during the survey).


Between 08/07/25 and 09/05/25 the resident experienced a severe weight loss of 8 pounds, or 6.7% of his/her total body weight, in one month. This change in weight constituted a severe loss and indicated a significant change of condition. There was no documented evidence the facility evaluated the resident, referred the significant weight loss to the facility nurse for assessment, documented the weight loss and updated the service plan.


A current weight for Resident 2 was requested on 10/07/25 at 12:26 pm. On 10/09/25 at 10:36 am the resident weighed 107 pounds.


From 09/05/25 through 10/09/25, the resident continued to lose weight, an additional 4.8 pounds, or an additional 4.3% of his/her total body weight.


During the survey the following was observed:


* On 10/07/25 for breakfast, Resident 2 consumed 50% of his/her scrambled eggs, two pieces of bacon, and a fruit cup. S/he initially attempted to eat with his/her fingers until intermittent assistance was provided from a care staff.

* On 10/09/25 for breakfast, Resident 2 consumed 100% of pears and 50% of scrambled eggs and cottage cheese. A care staff provided meal assistance until Resident 2 was finished.

During an interview on 10/07/25 at 3:05 pm, Staff 1 (Administrator) and Staff 2 (RCC) acknowledged Resident 2 had not been evaluated and referred to the facility nurse for the severe weight loss identified on 09/05/25.


Resident 2 experienced a severe weight loss on 09/05/25. The facility’s failure to ensure the resident’s severe weight loss was evaluated and referred to the facility nurse put the resident’s health and safety at risk. Resident 2 continued to experience additional weight loss after 09/05/25.

An immediate plan of correction was requested by the survey team on 10/09/25. The facility provided a plan of correction on 10/10/25 at 8:26 am, prior to survey exit. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation.


b. Fall prevention interventions listed on the 09/19/25 service plan included a wheelchair was used for mobility and Resident 2 required two person assistance for ambulation and transfers with use of a gait belt.

On 08/10/25 Resident 2 experienced a fall and sustained a femur (hip) fracture that required surgical repair. S/he returned to the facility on 08/18/25.

An evaluation was initiated on 08/19/25 with an ISP completed on 08/26/25 which instructed staff ensure Resident 2 “is in common area to reduce fall risk. When resident is in bed provide hourly checks. Ensure floor is free of clutter [sic] she is wearing appropriate footwear and is toileting frequently.”


Following the 08/10/25 fall, Resident 2 experienced the following four unwitnessed falls between 08/29/25 through 09/28/25:

* 08/29/25: Fall with skin tear to right arm;
* 09/24/25: Fall with “goose egg” to back of head and additional bruising was identified on 09/25/25;
* 09/27/25: Non-injury fall, found on floor in bedroom; and
* 09/28/25: Fall with wrist fracture, found with one shoe off.


On 08/31/25 the facility ISP instructed staff to "place on alert charting for 72 hours. Monitor for: Bruising, changes in mobility, decreased range of motion, increased need for assistance with ADL’s, or changes in condition. Provide increased amount of assistance as needed. Cue and remind resident to call for assistance with ADL’s, reaching for objects, answering the phone, etc. as needed and when feeling dizzy or weak. Remind the resident to use walker or wheelchair for mobility, to decrease further risk of falls." Additionally, an ISP dated 08/29/25 instructed staff to check on resident three times per shift to offer assistance and also monitor for dizziness/weakness.



An ISP, dated 09/24/25, for the 09/24/25 fall, had the same pre-determined instructions as the 08/31/25 ISP. No ISP had been completed for the non-injury fall on 09/27/25.


Although the facility completed ISPs for two additional falls on 08/29/25 and 09/24/25, there was no documented evidence the current interventions were reviewed for effectiveness or new interventions were developed, to help prevent possible future falls. On 09/28/25 Resident 2 had an additional fall and sustained a wrist fracture with an emergency room visit, resulting in a significant change of condition.


During an interview on 10/09/25 at 9:59 am, Staff 21 (CG) indicated he needed to “keep a close eye” on Resident 2. When the resident was awake, staff would ensure s/he was in the common area and when in bed, staff would complete hourly checks. He stated Resident 2 liked to stand up from the wheelchair often.

Observations of Resident 2 during the survey on 10/06/25 through 10/09/25 identified Resident 2 required staff to provide wheelchair escort, was not ambulatory, and needed two person assist with transfers. Staff provided hourly checks when s/he was in his/her room.

During an interview on 10/07/25 at 12:40 pm, Staff 1 (Administrator) confirmed there was no additional documentation current fall prevention interventions were reviewed for effectiveness following subsequent falls and if not determined effective, new interventions were put in place.

There was no documented evidence the facility monitored the existing fall prevention interventions at the time of each fall or for patterns related to the falls, determined and documented what new interventions were needed for the resident subsequent to each fall. The resident continued to have falls with injury and an emergency room visit that included a significant change of condition.


c. The facility lacked documented evidence the following short-term changes of condition were monitored at least weekly until resolution:

* 08/18/25: Return from the hospital;
* 08/18/25: Surgical incision following hip surgery;
* 08/29/25: Fall;
* 08/29/25: Skin tear to right arm;
* 09/24/25: Fall;
* 09/24/25: Bruising to back of head; and
* 09/25/25: Bruising to left bottom, right calf and left wrist.

d. On 09/29/25 the resident was prescribed oxycodone 5 mg 0.5 to 1 tablet PRN for severe pain following an emergency room visit for a wrist fracture. There was no documented evidence the resident had been monitored through resolution as to whether the pain control measures were effective and any adverse effects from the opioid pain medication.

The need to evaluate changes of condition, refer changes to the facility nurse when needed, determine actions or interventions and communicate them to staff, and monitor through resolution, with at least weekly documentation, was discussed with Staff 1, Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings.

3. Resident 1 moved into the community in 05/2023 with diagnoses including dementia.

The resident’s clinical record was reviewed and revealed the following:

The following short-term changes of condition lacked documentation the facility determined what resident specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/ or documented weekly progress until the condition resolved:

The facility created ISPs for three of four changes in dosage or administration frequency to PRN Lorazepam, however, the ISPs were not resident specific, nor was there evidence staff monitored the resident until resolution;

09/01/25: staff created an ISP identifying a “cut on left index finger,” but did not determine interventions or monitor for weekly progress until resolved;

09/12/25: staff created an ISP for a new order for Bupropion HCl (anti-depression medication) after it was discontinued for one week and reordered with dosage change, however, the ISP was not resident specific as to what side effects to monitor, nor did staff monitor the resident until resolution;

09/22/25: progress notes documented “red and irritated… cluster of pimple-like spots on resident’s right upper buttock,” but this was not communicated to staff, interventions were not determined, and the condition was not monitored through resolution;

09/26/25: staff created an ISP documenting a “ping pong sized yellow bruise on right shoulder blade,” however, interventions were not determined, nor was the condition monitored through resolution; and

10/03/25: staff created an ISP for a witnessed fall resulting in the resident hitting the “back of head,” however, the ISP did not specify what staff should monitor, and the condition was not monitored through resolution.

The need to ensure the facility documented short term changes of condition and determined resident specific interventions, communicated these interventions to staff, and monitored the resident for progress at least weekly until resolution was reviewed with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Operations Director) on 10/10/25 at 11:00 am. They acknowledged the findings.



4. Resident 3 was admitted to the facility in 09/2025 with diagnoses including dementia and depression.


A review of the resident’s clinical record and chart notes indicated the following:


Between 09/20/25 and 09/23/25 the resident started four new medications and had a dosage change to one of these new medications. The facility created ISPs informing staff of potential side effects, directing them to report changes from resident’s baseline to MT/LN. There was documentation from staff noting resident’s progress however no indication these short term changes of condition were resolved and monitoring discontinued.



The need to ensure changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 10/09/25 at 11:31 am. They acknowledged the findings and no further documentation was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment included documented findings, resident status, and interventions made as a result of the assessment for 2 of 3 sampled residents (#s 2 and 4) who experienced a significant change of condition. Residents 2 and 4 experienced ongoing, significant weight loss. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia.

The resident's service plan, dated 09/19/25, progress notes, dated 07/07/25 through 10/06/25, weight records, and interim service plans were reviewed.

a. Weight records showed Resident 2 experienced a severe and ongoing weight loss between 08/07/25 and 10/09/25:


* 08/07/25: 119.8 pounds;
* 09/05/25: 111.8 pounds; and
* 10/09/25: 107 pounds.


Between 08/07/25 and 09/05/25 the resident experienced a severe weight loss of 8 pounds, or 6.7% of his/her total body weight, in one month. This change in weight constituted a severe loss and indicated a significant change of condition, which required an RN assessment.


There was no documented evidence an RN assessment had been completed that included findings, resident status, and interventions made as a result of the assessment, after Resident 2’s severe weight loss was identified on 09/05/25.

A current weight for Resident 2 was requested on 10/07/25 at 12:26 pm. On 10/09/25 at 10:36 am the resident weighed 107 pounds.

From 09/05/25 through 10/09/25, the resident continued to lose weight, losing an additional 4.8 pounds, or an additional 4.3 % of his/her total body mass.

Refer to C 270, example 2a.

b. Resident 2 experienced the following:

* On 08/10/25 the resident experienced a fall with a right hip fracture and was hospitalized for surgery from 08/10/25 through 08/18/25.

* On 09/28/25 the resident experienced a fall with a left wrist fracture and resulted in an emergency room visit.

The hip and wrist fractures constituted a significant change of condition, for which an RN assessment was required. On 10/07/25 an RN assessment for the hip and wrist fractures were requested.

During an interview on 10/07/25 at 2:28 pm, Staff 17 (Health Services Director) acknowledged she had not completed an RN assessment for Resident 2’s left wrist fracture. She was recently hired in 09/2025 and was not employed when Resident 2 returned to the facility following surgery for the hip fracture.


During an interview on 10/10/25 at 12:15 pm, Staff 1 (Administrator) indicated there was no documented evidence an RN assessment had been completed for the hip or wrist fracture which documented findings, resident status, and interventions made as a result of the assessment. No further documented evidence was provided.

The need to ensure significant changes of condition were assessed by an RN and included findings, resident status, and interventions made as a result of the assessment was discussed with. Staff 1, Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings.


2. Resident 4 moved into the community in 10/2024 with diagnoses including dementia.

Review of the resident’s 09/12/25 service plan and interviews with direct care staff noted the resident ate a regular diet with thin liquids. Staff were instructed to provide finger foods when available. The resident required cueing and occasional feeding assistance. Resident 4 had a physician’s order for a wellness protein shake, one bottle, three times a day at 8:00 am, 1:00 pm and 6:00 pm.

Resident 4 was observed to consume the following foods during the survey:

* On 10/07/25 for breakfast, the resident consumed two medium sized pancakes with maple syrup and two sausage links;
* On 10/07/25 for lunch, the resident received assistance with feeding and consumed 100% of a Mexican casserole and steamed cauliflower and a small pastry for dessert; and
* On 10/08/25 for breakfast, the resident consumed a bowl of scrambled eggs with bacon and 10 oz of wellness protein shake.

Resident 4’s weight record noted the following:

* 04/08/25 – 121.4 pounds;
* 05/05/25 – 117.2 pounds;
* 06/04/25 – 106.9 pounds;
* 07/14/25 – 96.4 pounds;
* 08/02/25 – 101.2 pounds;
* 09/07/25 – 97.9 pounds;
* 10/05/25 – 90 pounds; and
* 10/07/25 – 96 pounds.

Between 05/05/25 and 06/04/25, the resident was noted to have lost 10.3 pounds, or 8.78% of his/her total body mass in one month. This constituted a severe weight loss and required an RN assessment.

There was no documented evidence an RN completed an assessment after Resident 4’ s severe weight loss was identified on 06/04/25.

From 06/04/25 through 10/05/25, the resident continued to lose weight, losing an additional 16.9 pounds, or an additional 15.8 % of his/her total body mass.

A current weight for Resident 4 was requested on 10/08/25. At 1:32 pm the resident was observed to weigh 96 pounds.

In an interview with Staff 1 (Administrator), on 10/08/25 at 11:02 am, she confirmed the lack of an RN assessment, which included findings, resident status, and interventions made as a result of the assessment, for Resident 4's severe and ongoing weight loss.

The facility's failure to ensure an RN assessment, which included findings, resident status and interventions made as a result of the assessment, was completed for Resident 4's severe and ongoing weight loss put the resident's health and safety at risk.

The need for the facility RN to assess significant changes of condition and document findings, resident status, and interventions made as a result of the assessment was discussed with Staff 17 (Health Services Director/RN) on 10/08/25 at 11:46 am and with Staff 1 (Administrator), Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 10:25 am. They acknowledged the findings. ?

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside services providers, to ensure staff were informed of new interventions, and the service plan was adjusted if necessary for 1 of 2 sampled residents (# 2) who received outside services. Findings include, but are not limited to:

Resident 2 moved into the community in 09/2023 with diagnoses including dementia.

Progress notes, dated 07/07/25 to 10/06/25, outside agency services notes, dated 09/03/25 to 10/03/25, and the service plan, dated 09/19/25, were reviewed, and interviews with staff were conducted.

There was no documented evidence staff were informed of the new instructions, and the service plan was updated, as necessary, for the following recommendations:

* 09/03/25 – HH PT note stated, “Encourage patient to move knees out and in when sitting in wheelchair can do 10-15 X up to every hour. Can walk with patient short distances but at this time would need 2 people supporting, 1 with wheelchair following and 1 standing with patient using walker and gait belt”;

* 09/06/25 – HH PT note stated “Focus to remain on encouraging separation between knees [right] knee [sic] out throughout the day. Encourage walking with staff assist. Frequency better than distance…”;

* 09/09/25 – HH PT note stated “Walk with patient 1-2X/day with walker. Encourage knees apart when sitting”;

* 09/11/25 – HH PT note “…Walk with walker frequency over distance 1 person assist”;

* 09/16/25 – HH nursing note instructed “Please keep dressing in place until PT visit. If dressing comes off, ok to leave OTA (open to air)”;

* 09/17/25 – HH PT note provided instructions for walking, “Requires 1 person assist, gait belt and shoes. Remind patient to keep knees apart when sitting.”; and

* 10/03/25 – HH OT note instructed “Please elevate L UE (left arm) periodically throughout day to [decrease] swelling, encourage [him/her] to wiggle fingers.” Also “Suggested stool softener…seems possibly constipated/impacted (seems firm (hard) when assisting [him/her] with peri-hygiene.) Encourage fluids.”

During an interview with Staff 2 (RCC) on 10/08/25 at 2:24 pm, she confirmed there was no documented evidence the HH instructions were communicated to staff. She indicated the MT would verbally communicate the information to staff and update the progress notes.

The need to ensure staff were informed of new interventions and the service plan was adjusted as necessary after on-site health services were provided was discussed with Staff 1(Administrator), Staff 2, and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to follow established infection prevention and control protocols to ensure a safe, sanitary, and comfortable environment for 2 of 3 sampled resident (#s 2 and 4) whose ADL care was observed, and for multiple sampled and unsampled residents during meal service. Findings include, but are not limited to:

During general resident observations on 10/07/25 at 9:41 am, Staff 6 (CG) was observed entering the unit carrying a plate of bite-sized pancake pieces and a cup of juice, setting them next to a resident whose wheelchair was positioned at the table. Without performing hand hygiene or donning gloves, she sat beside the resident and proceeded to hand the pieces of pancake to the resident.

The need to ensure infection prevention and control protocols were maintained to provide a safe, sanitary and comfortable environment was reviewed on 10/10/25 at 11:00 am with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations). They acknowledged the findings.



2. Resident 4 moved into the community in 10/2024 with diagnoses including dementia. The resident was identified as requiring occasional assistance with feeding during meal service.

Observations of meal service were completed between 10/06/25 and 10/09/25. Direct care staff were observed to serve meals and beverages to the residents, provide physical feeding assistance to Resident 4, collect soiled dishes and clean tables during meal service.

On 10/07/25 at 11:28 am, Staff 6 (CG) and Staff 12 (CG) were observed eating their individual lunches during the facility’s lunch meal service.

Staff 12 was observed standing at the kitchenette counter, eating from her plate of food. Staff 12 reached into a container and handed a resident a pastry using her bare hand. Staff 12 then began clearing resident’s dishes and pouring drinks for several residents. Staff 12 was not observed to perform hand hygiene after eating and before serving the pastry or pouring drinks for the residents. At 12:28 pm, Staff 12 was observed to use a paper towel to wipe her mouth and then used the same paper towel to wipe the kitchenette counter before throwing it in the garbage can.

At 12:26 pm, Staff 6 was observed seated at the kitchenette counter, next to Resident 4, rotating between feeding the resident with a fork out of the resident plate of food and feeding herself with a fork out of her own bowl of food using the same hand. Staff 6 was not observed to perform hand hygiene after eating and before feeding the resident.


The need to ensure infection prevention and control protocols were maintained was discussed with Staff 1 (Administrator), Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 10:25 am. They acknowledged the findings.





3. Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia. A review of his/her current service plan and interviews with staff revealed s/he was dependent on two staff for toileting tasks.



On 10/08/25 at 9:53 am, the surveyor observed two staff provide incontinence care for Resident 2 in bed. Prior to removing the soiled brief, a clean brief was pulled up onto the resident’s thighs. Resident 2 was assisted onto his/her side, the soiled brief was removed, not bagged and placed on the resident’s sheets and draw sheet, near the head of the bed. One staff used wipes to clean the perineal area and tossed the wipes onto the soiled brief. Prior to assisting the resident roll onto his/her back, the soiled brief and wipes were not bagged and tossed onto the floor. Additionally, staff did not change gloves between “clean” and “dirty” tasks and with the same soiled gloves were observed touching the resident’s legs, clean brief, draw sheet, bedding, and the pillow placed under the resident’s legs.



The need to ensure infection prevention and control protocols were followed was discussed with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system in place for tracking controlled substances administered by the facility, for 1 of 1 sampled resident (# 2) whose MARs and Controlled Substance Drug Disposition logs were compared for accuracy. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia.

Resident 2’s 09/29/25 through 10/07/25 MARs and Controlled Substance Disposition Log, dated 09/29/25/25 to 10/06/25, were reviewed and showed the following:

* Physician orders for oxycodone 5 mg to give 0.5 to 1 tab as needed every four hours for severe pain;
* A dose was signed out in the disposition log on 09/29/25 at 1:40 pm. The MAR reflected it was administered at 2:54 pm;
* A dose was signed out in the disposition log on 10/01/25 at 8:00 am. The MAR reflected it was administered at 8:44 am;
* A dose was signed out in the disposition log on 10/04/25 at 6:00 pm, and the dose was not reflected on the MAR;
* A dose was signed out in the disposition log on 10/05/25 at 8:30 am, and the dose was not reflected on the MAR;
* A dose was signed out in the disposition log on 10/05/25 at 5:00 pm. The MAR reflected it was administered at 4:14 pm; and * A dose was signed out in the disposition log on 10/06/25 at 3:00 pm. The MAR reflected it was administered at 3:55 pm.



The inconsistencies were reviewed on 10/07/25 at 2:28 pm with Staff 17 (Health Services Director). She indicated she was recently hired and was not aware of a process to review the Controlled Substance Drug Disposition logs for accuracy.

Comparison of the medication tablet bottle to the disposition log showed the amount of medication left was reflected accurately on the log.

The need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 1 (Administrator) on 10/07/25 and on 10/10/25 at 11:45 am with Staff 1, Staff 2 (RCC) and Staff 20 (Regional Director of Operations). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications that were ordered by a legally recognized provider and administered by the facility for 3 of 4 sampled residents (#s 1, 2 and 4) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 4 moved into the community in 10/2024 with diagnoses including dementia.

Resident 4’s 09/01/25 through 10/06/25 MARs were reviewed and the following orders were noted:

* Acetaminophen 650 mg suppository, one every six hours PRN (for moderate pain);
* Acetaminophen 650 mg suppository, one every six hours PRN (for mild pain or fevers); and
* Acetaminophen 325 mg tablet, two tablets every six hours PRN (for mild to moderate musculoskeletal pain, headache or fever above 100 degrees F).

The MAR did not indicate resident specific parameters and instructions for the PRN Acetaminophen suppository and tablets including the sequential order for administration of the medications which were prescribed for the same diagnoses.


On 10/10/25 at 10:26 am, the need to ensure MARs included resident specific parameters and instructions for PRN medications was discussed with Staff 1 (Administrator), Staff 2 (RCC) and Staff 20 (Regional Director of Operations). They acknowledged the findings.



2. Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia.

Resident 2's MARs, dated 09/01/25 through 10/09/25 were reviewed.

a. Resident 2 had two PRN medications for pain with conflicting parameters regarding sequential order of administration:


* Acetaminophen 325 mg give 2 tablets every four hours PRN mild pain; and
* Oxycodone 5 mg give 0.5 tablet PRN every four hours. “Additional Physician Directions: Take 0.5 tablet (one half) to 1 (one whole tablet) every 4 hours PRN for severe pain. Additional notes: give another 0.5mg if pain is severe.”

According to the 09/29/25 through 10/09/25 MAR, when both acetaminophen and oxycodone were prescribed, the resident was administered acetaminophen seven times and oxycodone 10 times.

b. Resident 2 had four PRN medications for constipation with conflicting parameters regarding sequential order of administration:

* Lactulose give 30 ml once daily PRN constipation or if resident eats gluten with no BM (bowel movement) in 24 hours;
* Milk of magnesia give 30 ML once a day if no BM in 3 days or if pt (patient) reports constipation;
* Polyethylene glycol give once a day as needed *start 72 hours after no BM; and
* Senna-Time 8.6 mg give 2 tablets once a day as needed for constipation.

Resident 2 had been administered lactulose one time in September and one time in October. Milk of magnesia was administered two times in October. Polyethylene glycol and senna-time had not been administered.


During an interview on 10/08/25 at 1:30 pm, Staff 4 (MT) acknowledged the lack of instructions for which medication to take first for pain and/or constipation. “I use my best judgement” regarding which PRN medication she provided for constipation. “If [s/he] is super impacted I will use the milk of magnesia over polyethylene glycol.”


The need to ensure medications on the MARs included reason for use, and resident-specific parameters for PRN medications was discussed with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings.



3. Resident 1 moved into the community in 05/2023 with diagnoses including dementia.

The resident’s MAR dated 08/01/25 - 10/06/25, corresponding physician orders, and progress notes dated 07/11/25 through 10/05/25 were reviewed. The following was identified:

Resident 1 had orders for Lorazepam 0.5 mg sublingual tablet: give two tablets as needed for mild agitation/ anxiety/ dyspnea.

Progress notes documented administration of the Lorazepam on five occasions in August and once in September, but these administrations were not on the MAR.

The need to ensure residents’ MARs were accurate was reviewed with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:00 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medications that were given to treat a resident's behavior had resident specific parameters including when to contact a health professional regarding side effects, non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 3 of 3 sampled residents (#s 1, 2, and 3) who were prescribed and administered a PRN psychotropic medication. Findings include, but are not limited to:

1. Resident 1 moved into the community in 05/2023 with diagnoses including dementia.

The resident’s MAR dated 08/01/25 - 10/06/25, corresponding physician orders and progress notes were reviewed, and interviews with staff were conducted. The following was identified:

The resident had orders for PRN two Lorazepam 0.5 mg sublingual tablets every two hours for mild agitation/ anxiety/ dyspnea. The MAR indicated the resident received the medication 25 times between 08/01/25 and 10/06/25. The resident’s record lacked documented evidence non-pharmaceutical interventions were attempted and/ or documented as ineffective for 23 of the 25 administrations. The record also lacked instruction to staff on when to contact a health professional regarding side effects.

For four of the six Lorazepam administrations not recorded on the MAR, there was no documented evidence staff attempted non-pharmaceutical interventions and/ or documented them as ineffective prior to administering the medication.

On 10/07/25 at 11:23 am, Staff 3 (MT) confirmed there was no information on the MAR as to non-pharmaceutical interventions staff should attempt prior to administering the Lorazepam, nor was there information regarding how or when to contact the prescriber if the resident experienced adverse side effects.

The need to ensure PRN medications administered to treat a resident’s behavior had resident specific parameters and non-pharmacological interventions were documented as attempted with ineffective results prior to the administration of PRN psychotropics was reviewed with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:00 am. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia.

Review of the resident's MAR dated 09/01/25 through 10/09/25, current physician orders, and progress notes identified the following:

The resident had orders for Lorazepam 0.5 mg every eight hours as needed for anxiety or agitation. The MAR indicated the resident received the medication 11 times between 09/01/25 and 10/08/25.

The MAR did not contain resident-specific parameters for staff describing how the resident expressed anxiety or agitation and there was no documented evidence that non-pharmacological interventions had been tried first with ineffective results. Additionally, the record lacked instruction to staff on when to contact a health professional regarding side effects.

During an interview on 10/07/25 at 12:25 pm, Staff 4 (MT) acknowledged the MAR lacked non-pharmacological interventions to be attempted prior to administration of the PRN lorazepam. She also confirmed there were no instructions on when to call if the resident experienced side effects from the lorazepam.

The need to ensure medications given to treat a resident's behavior had resident-specific parameters, non-pharmacological interventions were attempted and documented as ineffective prior to the administration for psychotropic medications, and when to contact the prescriber if the resident experienced adverse side effects was discussed with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings.









3. Resident 3 was admitted to the facility in 09/2025 with diagnoses including dementia and depression.

Review of the resident's MAR dated 09/01/25 through 10/13/25, current physician orders, and progress notes identified the following:

Risperidone 0.5 mg every twelve hours as needed for agitation. The risperidone PRN dose was administered on 09/25/25, 9/28/25 and 10/06/25.

The MAR did not contain resident-specific parameters for staff describing how the resident expressed agitation and there was no documented evidence non-pharmacological interventions had been tried first with ineffective results.

The need to ensure medications given to treat a resident's behavior had resident-specific parameters and non-pharmacological interventions were attempted and documented as ineffective prior to the administration for psychotropic medications was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 10/09/25 at 11:31 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs. Findings include, but are not limited to:



a. During the acuity interview at 10:52 am on 10/06/25 the following was reported:

* The facility was a one story MCC with two segregated units separated by locked doors and a lobby. The facility had a current census of 40 residents; and



* Five residents required a two-person assist to transfer, four resided in the Mountainside unit and one in the Riverside unit;

b. The facility reported on the Acuity-Based Staffing Tool (ABST) Facility Entrance Questionnaire the following:
* All 40 residents were identified as having support for behavioral symptoms; and
* All 40 residents were identified as having support for cognitive impairments.

c. The staffing plan posted by the facility was as follows:

* Mountainside unit: day shift: 2 CGs and 1 MT, swing shift: 2 CGs and 1 MT,
* Riverside unit: day shift: 2 CG and 1 MT, swing shift: 2 CGs and MT 1; and
* Mountainside and Riverside units: night shift, 1 CG and 1 MT shared between the two units.

d. Review of the facility staffing schedule for night shifts from 09/28/25 through 10/06/25 revealed the following:

* On 09/28/25, 09/29/25, 09/30/25, 10/01/25, and 10/05/25 the facility staffed only one direct care staff for the Mountain unit; and
* On 10/02/25, 10/03/25, and 10/04/25, the facility staffed one direct care staff for both Riverside and Mountainside units.

e. Interviews with direct care staff conducted on 10/06/25 confirmed the four residents in Mountainside unit and one resident in Riverside unit who required two-person assistance with transfers.

The night shift staffing plan did not include a minimum of two direct care staff in each segregated unit whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs.
The need to ensure a minimum of two direct care staff was scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs was discussed with Staff 1 (Administrator), Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 10: 25 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to adopt a proprietary Acuity-Based Staffing Tool (ABST) that addressed and documented all required individual care elements. Findings include but are not limited to:

Review of the ABST Facility Questionnaire and ABST documents provided by the facility on 10/09/25 at 9:26 am found the facility’s proprietary ABST did not address all required individual care elements, including the following:

* Repositioning;
* Providing treatments;
* Cueing or redirecting due to cognitive impairment or dementia;
* Ensuring non-drug interventions for behaviors;
* Responding to call lights;
* Monitoring physical conditions or symptoms; and
* Safety checks and fall prevention.

In an interview on 10/10/25 at 9:26 am, Staff 1(Administrator) confirmed the proprietary ABST did not address each required individual care elements and did not include the staff time needed to complete each individual care element.

On 10/10/25 at 10:26 am, the need to ensure the proprietary ABST addressed and documented all required individual care elements was discussed with Staff 1, Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 10: 25 am. They acknowledged the findings.

Based on observation, interview, and record review it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) developed reports that reflected distinct and segregated areas and accurately captured care time and care elements staff were providing to residents for 4 of 4 sampled residents (#s 1, 2, 3 and 4). Findings include, but are not limited to:

1. Observations made during the survey found the facility was a one story MCC with two segregated units separated by locked doors and a lobby. Review of ABST documents provided by the facility on 10/09/25 at 9:26 am found the facility’s proprietary ABST did not provide an ABST report that reflected the distinct and segregated areas of the facility.

2. Resident 4 was admitted to the facility 10/2024 with diagnoses including dementia.

The service plan, dated 09/12/25, Interim Service Plans, and the resident's corresponding ABST record were reviewed. The resident was observed, and interviews were conducted with staff. The resident's care time and care elements were found to be not reflective in the following areas:

* Transfers;
* Supervising, cueing, or supporting while eating;
* Medication administration;
* Cueing or redirecting due to cognitive impairment or dementia;
* Providing treatments;
* Monitoring behavioral conditions or symptoms;
* Ensuring non-drug interventions for behaviors; and
* Assisting with leisure activities, assist with social and recreational activities.

The need to ensure the facility ABST developed reports that reflected distinct and segregated areas and accurately captured care time and care elements that staff were providing was discussed with Staff 1 (Administrator), Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 10:25 am. They acknowledged the findings.



3. Resident 1 moved into the community in 05/2023 with diagnoses including dementia.

The resident’s service plan, dated 09/26/25, interim service plans, and the resident’s ABST were reviewed. The resident was observed and interviews with staff were conducted. The resident’s care time and care elements were found to be not reflective in the following areas:

Toileting, bowel, and bladder management;
Bathing;
Medication administration;
Cueing or redirecting due to cognitive impairment or dementia;
Ensuring non-drug interventions for behaviors;
Assisting with leisure activities, assist with social and recreational activities;
Monitoring physical conditions or symptoms; and
Safety checks, fall prevention.

The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 1(Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:00 am. They acknowledged the findings.


4. Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia.


The service plan, dated 09/19/25, Interim Service Plans, and the resident's corresponding ABST record were reviewed. The resident was observed, and interviews were conducted with staff. The resident's care time and care elements were found to be not reflective in the following areas:



* Assisting with communication;
* Transfers;
* Supervising, cueing, or supporting while eating;
* Safety checks and fall prevention;
* Monitoring behavioral conditions or symptoms;
* Ensuring non-drug interventions for behaviors; and
* Dressing and undressing.

The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 1 (Administrator), Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings.

5. Resident 3 was admitted to the facility 09/2025 with diagnoses including dementia and depression.

The service plan, dated 10/06/25, Interim Service Plans, and the resident's corresponding ABST record were reviewed. The resident was observed and interviews were conducted with staff. The resident's care time and care elements were found to be not reflective in the following areas:


* Toileting, bowel, and bladder management;
* Medication administration;
* Cueing or redirecting due to cognitive impairment or dementia;
* Monitoring behavioral conditions or symptoms;
* Ensuring non-drug interventions for behaviors; and
* Safety checks, fall prevention.

The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 10/09/25 at 11:31 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to update and review the acuity-based staffing tool (ABST) evaluation when a resident experienced a significant change of condition for 2 of 2 sampled residents (#s 2 and 4) who experienced a significant change in condition. Findings include, but are not limited to: ?

1. Resident 4 moved into the community in 10/2024 with diagnoses including dementia.

Review of Resident 4’s ABST and clinical records during the survey identified the resident experienced a significant change in condition due to a severe weight loss between 05/2025 and 06/2025. The facility failed to update and review the ABST no less than quarterly at the same time the resident’s service plan was updated.

The above findings were discussed with Staff 1 (Administrator), Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 10:25 am. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia.

The service plan, dated 06/19/25, progress notes, dated 07/07/25 to 10/06/25, and the resident’s corresponding ABST evaluation were reviewed.

It was noted Resident 2 experienced a significant change of condition on 09/28/25 following a fall with a wrist fracture. However, the last ABST evaluation update for the resident was dated 09/18/25.

The need to ensure the ABST was updated and reviewed whenever there was a significant change of condition was discussed with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 10, 13, and 16) demonstrated competency in first aid and/or abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 10/09/25 at 11:40 am with Staff 14 (Operations & Administration Director) and the following was identified:

Staff 10 (CG), Staff 13 (MT), and Staff 16 (CG), hired 05/12/25, 06/23/25, and 08/13/25, respectively, lacked documented evidence they had completed first aid and/or abdominal thrust training within 30 days of hire.

During an interview on 10/09/25 at 11:40 am with Staff 14, she acknowledged Staff 10 and Staff 13 did not have either first aid or abdominal thrust training. Staff 16 had taken first aid training but Staff 14 acknowledged it did not include abdominal thrust training.

The need to document demonstrated competency of job duties within 30 days of hire was discussed with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 10, 13, and 16) demonstrated competency in first aid and/or abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 10/09/25 at 11:40 am with Staff 14 (Operations & Administration Director) and the following was identified:

Staff 10 (CG), Staff 13 (MT), and Staff 16 (CG), hired 05/12/25, 06/23/25, and 08/13/25, respectively, lacked documented evidence they had completed first aid and/or abdominal thrust training within 30 days of hire.

During an interview on 10/09/25 at 11:40 am with Staff 14, she acknowledged Staff 10 and Staff 13 did not have either first aid or abdominal thrust training. Staff 16 had taken first aid training but Staff 14 acknowledged it did not include abdominal thrust training.

The need to document demonstrated competency of job duties within 30 days of hire was discussed with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure each resident was instructed within 24 hours of admission and re-instructed, at least annually, in fire and life safety procedures. Findings include, but are not limited to:

Facility fire and life safety records were reviewed on 10/08/25. The facility lacked documented evidence residents were instructed in general safety procedures, evacuation methods, and responsibilities during fire drills within 24 hours of admission and at least annually.

In an interview with Staff 18 (Maintenance Manager) on 10/08/25 at 8:08 am, he confirmed there was no system in place for instructing residents of the facility’s fire and life safety procedures.

The need to ensure the facility instructs residents on fire and life safety procedures within 24 hours of admission and at least annually was reviewed with Staff 1 (Administrator), Staff 2 (RCC) and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:00 am. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure individual rights of privacy, dignity, and respect for sampled residents (#s 1, 2, 3 and 4) and multiple unsampled residents. Findings include, but are not limited to:

During the acuity interview on 10/06/25 and observations made during the survey, it was identified residents 1, 2, 3 and 4 and multiple unsampled residents' service plans were kept in binders found in the common area of each memory care unit. The service plans were accessible to residents and visitors who entered the units.

The need to ensure residents’ right to have medical and other records kept confidential was reviewed with Staff 1 (Administrator) on 10/07/25 at 2:50 pm. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure each individual had privacy in his or her own unit for 2 of 4 sampled residents (#s 1 and 4) and multiple unsampled residents who shared a bathroom. Findings include, but are not limited to:

1. Observations of Riverside and Mountainside units were conducted on 10/06/25 and 10/07/25. The shared bathrooms all had two doors that would each open to a different resident unit. The doors could be locked from the residents’ rooms, but not from inside the bathroom. Therefore, each individual was not ensured privacy when using his/her shared restroom.

The need to ensure each resident had privacy in his or her own unit was reviewed with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:00 am. They acknowledged the findings.


2. Resident 4 was admitted to the facility in 10/2024 with diagnoses including dementia.

On 10/08/25 at 10:03 am, Staff 3 (MT) and Staff 19 (CG), were observed providing ADL care to Resident 4 in the resident’s unit. Staff 3 and Staff 19 removed the resident’s pants and soiled brief and provided incontinent care to the resident without closing the blinds to the unit window that look out into the facility courtyard. There were two residents in the courtyard, within line of sight of the window at the time staff were providing ADL cares to Resident 4.

On 10/10/25 at 10:25 am the need to ensure residents’ right to dignity and privacy in their own unit was discussed with Staff 1 (Administrator), Staff 2 (RCC) and Staff 20 (Regional Director of Operations. They acknowledged the findings.

Based on interview and record review, the facility failed to ensure move-in evaluations addressed all required elements, including pronouns and gender identity, for 1 of 1 sampled resident (#4) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Refer to: C 252

Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight for the operation of the facility and to ensure the quality of services rendered in the facility. Findings include, but are not limited to:

During the change of ownership survey, conducted 10/06/25 through 10/10/25, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of the citations.

1. A situation was identified which constituted an immediate threat to the health and safety of the residents in the following areas:

* C0270: OAR 411-054-0040 (1-2) Change of Condition and Monitoring; and

* C0280: OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health and Services.



The facility developed and implemented an immediate plan of correction during the survey to address the threat to residents' safety, and the immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation.

2. Refer to deficiencies in the report.

Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight for the operation of the facility and to ensure the quality of services rendered in the facility. Findings include, but are not limited to:

During the change of ownership survey, conducted 10/06/25 through 10/10/25, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of the citations.

1. A situation was identified which constituted an immediate threat to the health and safety of the residents in the following areas:

* C0270: OAR 411-054-0040 (1-2) Change of Condition and Monitoring; and

* C0280: OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health and Services.



The facility developed and implemented an immediate plan of correction during the survey to address the threat to residents' safety, and the immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation.

2. Refer to deficiencies in the report.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired staff (#s 10, 13, 15, and 16) completed all required pre-service orientation training topics; 3 of 3 newly-hired direct care staff (#s 10, 13, and 16) completed all required pre-service dementia training topics and demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 10/09/25 at 11:40 am with Staff 14 (Operations & Administration Director). The following was identified:


a. There was no documented evidence Staff 10 (CG), Staff 13 (MT), Staff 15 (Cook) and Staff 16 (CG), hired 05/12/25, 06/23/25, 07/28/25, and 08/13/25, respectively, had completed one or more of the following pre-service orientation topics before completing any job duties:

* Resident rights and values of CBC care;
* Abuse reporting requirements;
* Food handler’s certificate;
* Infectious disease prevention;
* HCBS course;
* LGBTQIA2S+ course;
* Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms;
* Techniques for understanding, communicating and responding to distressful behavioral symptoms;
* Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and
* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of a person-centered approach.

b. There was no documented evidence Staff 10, Staff 13 and Staff 16 completed one or more of the following pre-service dementia training topics for direct care staff:

* Environmental factors that are important to a resident’s well-being (e.g., staff interactions, lighting, room temperature, noise, etc.);
* Family support and the role the family may have in the care of the resident;
* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;
* How to provide personal care to a resident with dementia; and
* Use of supportive devices with restraining qualities in memory care communities.

c. There was no documented evidence Staff 10, Staff 13 and Staff 16 demonstrated competency in one or more of the following areas within 30 days of hire:


* Role of service plans in providing individualized care;
* Changes associated with normal aging;
* Identification, documenting and reporting of changes of condition;
* Conditions that require assessment, treatment, observation and reporting; and
* General food safety, serving and sanitation.

The need to ensure the required pre-service training was completed by staff in the time frames specified in the rules and staff demonstrated competency in assigned job duties within 30 days of hire was discussed on 10/09/25 at 11:40 am with Staff 14, and with Staff 1 (Administrator), Staff 2 (RCC), and Staff 20 (Regional Director of Operations) on 10/10/25 at 11:45 am. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C252, C260, C270, C280, C290, C302, C310, C361, C362 and C363.

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed for each resident and was included in the service plan for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose nutrition and hydration plans were reviewed. Findings include, but are not limited to:

Residents 1, 2, 3 and 4’s current service plans were reviewed during survey. Each service plan lacked information and/or staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident.

The need to develop an individualized nutrition and hydration plan based on the resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 1 (Administrator) and Staff 2 (RCC) on 10/09/25 at 11:31 am. They acknowledged the findings and no further documentation was provided.

Based on interview and record review, it was determined the facility failed to ensure each resident was evaluated for activities addressing all required elements and to develop an individualized activity plan based on their activity evaluation for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose evaluations and services plans were reviewed.

The most recent evaluations and current service plans were reviewed for Residents 1, 2, 3 and 4. The following was identified:

a. There was no documented evidence an activity evaluation had been completed for sampled residents that addressed the following:


* Past and current interests;
* Current abilities and skills;
* Emotional and social needs and patterns;
* Physical abilities and limitations;
* Adaptations necessary for the resident to participate; and
* Identification of activities for behavioral interventions.

b. There was no documented evidence an individualized plan was developed for the sampled residents.

The need to ensure activity evaluations were completed and individualized activity plans were developed was discussed with Staff 1 and Staff 2 (RCC) on 10/09/25 at 11:31 am. The findings were acknowledged, and no further documentation was provided.

Based on interview and record review conducted during a site visit on 07/17/24 it was determined the facility failed to implement a service plan that reflects the resident's needs as identified in the evaluation for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:A review of Resident 1's service plan, dated 06/17/24, indicated Resident 1 was admitted to hospice care on 03/05/24.Resident 1's Alert Charting, dated 06/23/24, indicated Resident 1 was sick, had a fever, was refusing medication. Resident 1 was transported to the hospital and would stay in the hospital overnight. There was no documented evidence Resident 1's hopsice provider had been notified prior to Resident 1 being sent to the hospital.In an interview with Staff 1 (Administrator) s/he stated s/he had been on the job for three days at the time of the incident and had not been aware Resident 1 was on hospice. Staff 1 stated the facility had made an error. The findings were reviewed with and acknowledged by Staff 1 on 07/17/24.Verbal plan of correction: Facility to hold a staff meeting to ensure familiarization with resident care plans.

Based on observation, interview, and record review, conducted during a site visit on 07/17/24, it was determined the facility failed to fully implement and update an acuity-based staffing tool (ABST) for 3 of 3 sampled residents (#s 1, 2, and 3). Findings include, but are not limited to:Staff 1 (Administrator) stated the facility had been using the Oregon Department of Human Services ABST tool, but after a management take over they were moving to "Yardy" ABST and s/he was responsible for updating it. Staff 1 confirmed the posted staffing plan had not been updated to reflect the ABST and s/he had not entered all of the resident service plans as required.Service planned needs for were not entered for Residents 1, 2, and 3.The ABST had not been updated as required for all 42 residents in the facility.The facility's posted staffing plan indicated:* Day shift: two full time caregivers and one med tech scheduled from 6:00 am to 2:00 pm, for each side.* Swing shift: two full time caregivers and one med tech scheduled from 2:00 pm to 10:00 pm, for each side.* Night shift: one caregiver and a float (shared for each side) and one med tech from 10:00 pm to 6:00 am for each side. The facility's staffing plan was not reflective of the ABST. Staff schedules for June 2024 indicated staffing levels were at the posted staffing plan but not reflective of recommended ABST hours as they were not entered.On 07/17/24, the facility was staffed per the schedule and staffing plan for the day shift of two caregivers and one med tech per side.The above information was shared on 07/17/24 and acknowledged by Staff 1.It was determined the facility had not fully implemented an ABST. PLAN OF CORRECTION: Enter resident care plans into ABST Tool.

The findings of the kitchen inspection, conducted 02/26/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 02/26/24, conducted 05/09/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000 and OARs 411 Division 57 for Memory Care Communities.

Based on observation, interview, and record review, it was determined the facility failed to ensure food was prepared and the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the kitchen, food storage, food preparation, and service on 02/26/24 revealed:Spills, splatters, and debris were noted:- The knobs, handles, sides and interior of the range;- Interior of drawers throughout the kitchen;- Interior of the deli and reach in refrigerator;- The open shelving and shelving legs throughout the kitchen; - Stand mixer;- Floor drains; and- The dishwashing area and equipment.* Staff 2 (Executive Chef) explained the facility used auto dispense Quaternary solution for the sanitizer. There was no documented evidence it was monitored to ensure the correct solution. The sanitizer was tested and found to be at the correct parts per million. Wet towels were noted on the tray line cutting boards and in the food preparation area. Buckets were not available to fully submerge the towels for sanitizing.* Scoops were left in all bins of dry foods. * Multiple prepared food items in the deli and reach in refrigerators were not dated or labeled.* Multiple packaged food items in all refrigerators and dry storage were not dated when opened.The areas in need of cleaning and food storage guidelines were reviewed with Staff 1 (Executive Director) and Staff 2 (Executive Chef) on 02/26/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 240.

The findings of the re-licensure survey conducted 05/08/23 through 05/11/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules.Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the re-visit to the re-licensure survey of 05/11/23, conducted 08/03/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

2. Resident 6 was admitted to the facility in February 2017 and was identified to utilize a urinary catheter.On 05/09/23 at 1:20 pm, Resident 6 was observed seated in a low recliner in his/her room, dressed in a t-shirt, and incontinent product with the tubing of the catheter on the floor. The night bag was hung on a wheelchair next to the resident. Staff 17 (CG) was notified Resident 6 needed assistance. The resident was assisted to get dressed for the day and the catheter was changed to a leg bag.On 05/10/23 at 9:15 am, Resident 6 was observed seated in a low recliner in his/her room with the tubing and catheter night bag on the floor.Staff 2 (RN) observed the resident and the catheter bag on the floor. She acknowledged the catheter was improperly managed and posed an infection control risk.
Based on observation and interview, it was determined the facility failed to implement effective methods of infection control and to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in September 2019 with diagnoses including dementia.On 05/09/23 at 9:40 am, the surveyor obtained permission and observed Staff 2 (RCC) and Staff 15 (CG) provide incontinent care for Resident 2. During the observation, Staff 15 failed to change gloves after removing a soiled incontinent product and wiping feces from Resident 2's perineum. Staff 2 (RCC) and Staff 15 (RCC) were observed placing a soiled incontinent product and soiled wipes on the floor of Resident 2's room.The need for reasonable precautions to be exercised against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 1 (ED) on 05/11/23 at 2:30 pm. The findings were acknowledged.

Based on observation and interview it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the facility's lunch service on 05/10/23 revealed:* Staff were observed to not change gloves between tasks during meal service while touching ready to eat food;* Staff did not practice hand hygiene between dirty and clean tasks, i.e. bussing dirty dishes and serving beverages and food; and* Caregiving staff assisting with meal service and delivery did not don aprons.The food handling and infection control observations were reviewed with Staff 1 (ED) on 5/10/23. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 160 and C 240.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly hired staff demonstrated and documented competency in all required areas within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 05/09/23 and 05/10/23. The following was identified:There was no documented evidence Staff 19 (CG) hired 09/26/22, demonstrated competency in the following areas within 30 days of hire:* Role of service plans in providing individualized care;* Providing assistance with ADL's;* Identification, documentation, and reporting of changes of condition;* Conditions which require assessment, treatment, observation, and reporting; and* General food safety, serving and sanitation.Staff 1 (ED), in an interview on 05/10/23, reported she had no further documentation related to the 30 day competency completion for the staff reviewed. The need to ensure all new hires demonstrated competency in job duties within 30 days of hire was discussed with Staff 1 (ED) on 05/10/23. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the resident, and failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 4 of 6 sampled residents (#s 1, 2, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:Resident 1, 2, 4 and 5's service plans offered some information about the residents' interests, but the facility had not fully evaluated the residents':* Current abilities and skills;* Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary.Observations on 05/08/23 and 05/09/23 showed Resident 1, 2 and 5 in their rooms without any staff interaction. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities.The need to ensure all residents had individualized activity plans developed and implemented to engage them in meaningful activities was discussed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 4 (Activities Director) on 05/11/23. They acknowledged the findings.